Benign Prostatic Hypertrophy

Benign Prostatic Hypertrophy

Cause.
Benign prostatic hypertrophy (BPH) rarely affects men <40 years of age, with symptoms generally beginning between 60 to 65 years of age.

Clinical Presentation.
Signs and symptoms include decreased force and caliber of urinary stream, hesitancy, retention, postmicturition dribbling, double voiding (patient voids and is able to void again in 5 to 10 minutes), and overflow urinary incontinence (on straining or coughing). Irritative symptoms such as dysuria, frequency, nocturia, urgency, hematuria, and incontinence occur frequently. Flank pain during micturition, suprapubic pain, and azotemic symptoms occur less commonly.
Exam. The bladder may be distended, and the prostate is enlarged, smooth, and symmetric. The prostate gland may be soft or firm and possibly nodular. However, the nodules lack the stony-hard consistency associated with carcinoma.
Laboratory findings. UA may reveal signs of infection. If the obstruction has been severe enough to impair renal function, BUN and creatinine may be elevated. PSA may be elevated.
Radiographic findings. IVP may show upper tract or bladder changes secondary to obstruction (hydroureteronephrosis, bladder trabeculation and thickening, bladder diverticula or calculi). VCUG may be indicated. Postvoid catheterization will reveal residual urine. Order an ultrasonogram with rectal probe and biopsies if indicated, to rule out carcinoma. Cystoscopy if indicated.
Uroflowmetry. It is the most frequently used and most informative though nonspecific method of diagnosing bladder neck obstruction. Maximum flow rate should be >15 ml/sec. Flow rate of <10 ml/sec usually indicates infravesical obstruction.
Postvoid residual urine. It is a useful tool for follow-up and evaluation of response to therapy.
Pressure flow studies. These are indicated in patients with normal peak flow rates but with symptoms suggestive of infravesical obstruction and patients with symptoms suggestive of bladder voiding dysfunction.

Treatment.
Men with mild symptoms may be managed by watchful waiting. Those with moderate symptoms may be managed by medical treatment. Those with severe symptoms are candidates for surgical treatment. An indwelling Foley catheter may help acute episodes but is only a temporary measure.
Medical measures. Terazosin 1 to 2 mg/day is often helpful in relieving symptoms. Tamsulosin 0.4 to 0.8 mg/day may be helpful, but it is more expensive. Finasteride (Proscar) 5 mg PO QD blocks transformation of testosterone to 5a-dihydrotestosterone. Shrinks prostate tissue but may take 6 to 12 months to have a clinical effect. Hyper- trophy recurs on stopping drug. Recent data indicate that finasteride may be no better than placebo at relieving symptoms of benign pros-tatic hypertrophy.
Surgical measures. Transurethral prostatectomy (TURP) is the gold standard surgical treatment, but it should not be performed in patients who want to remain fertile. There is a significant incidence of incontinence and impotence following TURP.
Antibiotics should be used to control infection when indicated.
If exam reveals nodularity of the gland, referral to a urologist is indicated.

A 54-year old woman complains of hot flashes and night sweats. Her last menstrual period was 2 years ago. She also has migraine headaches and a family history of breast cancer via her maternal aunt. What is the appropriate treatment for her?


A: Hysterectomy.
B: Endometrial Biopsy.
C: Medroxyprogesterone Acetate.
D: Estrogen Cream.
E: Estrogen and Progestin therapy.

Answer is C.
This 54-year old woman has vasomotor instability and needs hormonal replacement. Because she has two contraindications to estrogen therapy; migraine headaches and a family history of breast cancer, Medroxyprogesterone acetate is the best treatment of choice. Even though it is less effective than estrogen, it still can offer symptomatic relief.
There is no indication for an Endometrial Biopsy in this patient. A Hysterectomy is the treatment for a woman with early stages of endometrial cancer.

A 68-year old female with a history of chronic constipation presents to the emergency room with a two day history of abdominal pain and fever. The patient states that she has not wanted to eat for 3 days and she has vomited several times today with several episodes of diarrhea. She has a history of a myocardial infarction six years ago and is concerned because she was feeling some palpitations over the past 24 hours. She has no history of prior abdominal surgeries and only takes sublingual nitroglycerin as needed. Physical examination is notable for a thin female, who appeared older than her stated age. Temperature was 101.5, blood pressure - 110/70, heart rate-112, and respiration rate is 14.

HEENT; normal, no JVD, mucus membranes were dry. Cardiac- tachycardic, regular rate, Lungs- clear, Abdominal exam- a distended abdomen with minimal bowel sounds, she is tender in the left lower quadrant with the suggestion of a mass. She does not have rebound or guarding. Rectal exam confirms a fullness in the left lower quadrant and reveals guaiac negative stool. All of the following are reasonable treatment modalities given the patients clinical presentation, EXCEPT:


A: IV hydration.
B: Nothing by mouth.
C: Nasogastric tube.
D: Immediate surgery.
E: CT scan.

Answer is D.

This is a very typical case scenario in the real world. An elderly patient with a history of prior medical problems and of course constipation presents with worsening abdominal complaints.
Once it is ascertained that the patient does not have an acute abdomen, the differential and further diagnostic studies can be pursued- if the patient had an acute abdomen it would not matter if she had a perforated colon carcinoma or diverticulitis, she would need immediate surgical therapy. The differential in this patient should at the very least include ovarian torsion, ischemic colitis, diverticulitis, sigmoid volvulus and colon carcinoma.
Since this patient did not have focal peritoneal signs- immediate surgery is not needed and further evaluation would be helpful- CT scan. In the interim, making the patient NPO, restoring the extracellular fluid deficits, and placing an NGT for gastric decompression are all prudent measures. Once the CT scan rules out a mass lesion in the sigmoid colon the diagnosis of diverticulitis becomes more likely. In this case, initial conservative treatment consisting of IV antibiotics and observation is reasonable.
Autopsies and radiologic studies reveal that 35-50% of patients have diverticular disease. The incidence is directly related to the patient's age-- <5% at the age of 40, 30% by the age of 60 and > 65% in patients older than 85. The incidence is also higher in industrialized countries and probably is related to the higher incidence of low fiber diets. Only 10-25% of patients with diverticula develop symptomatology of diverticulitis and another 15% develop bleeding complications. Patients with mild symptoms can be treated conservatively with good results. However, patients that present with a free abdominal perforation require immediate surgery and can have up to a 20% mortality. After the first attack only one third will have a second attack, although another 30-40% will have vague symptoms. After a second attack, only 10% will remain symptom free and this becomes another indication for surgical intervention.

A 58-year old man with a history of chronic bronchitis and tobacco use presents to the Emergency Room with a 2-day history of a 3 cm. groin mass and a 12-hour history of nausea and vomiting. He denies any prior abdominal surgeries. Examination reveals a firm, tender left groin mass which is not mobile. The scrotum, testis, and penis were all normal. Abdominal X-rays reveal multiple air fluid levels. The most likely diagnosis is:

A: Metastatic lung cancer to the inguinal nodes.
B: Incarcerated inguinal hernia.
C: Viral gastroenteritis with inguinal adenopathy.
D: Spigelian hernia.
E: Undescended testis.

Answer is B.
This is a surgical emergency. This patient is presenting with an incarcerated hernia and a small bowel obstruction. He must be taken to the operating room immediately for reduction of the hernia and relief of the bowel obstruction before the incarcerated bowel becomes gangrenous. An untreated inguinal hernia may become incarcerated if a loop of bowel or piece of omentum descends through the abdominal wall defect and cannot return to the peritoneal cavity. Subsequent venous congestion leads to edema and eventually arterial compromise to the incarcerated structure. Sometimes incarcerated hernias present early before this edema and are able to be reduced with manipulation and sedation. In this case the immobility and firmness of the mass suggests that this will not be possible and surgical reduction is the only alternative. A spigelian hernia is a lateral ventral wall defect. A normal testis examination rules out an undescended testis and would not account for his gastrointestinal symptoms. Air fluid levels on the x-ray are consistent with a bowel obstruction and should not be seen with gastroenteritis.

Which one of the following depressed patients is most likely to commit suicide?


a.A 26-year-old male who repeatedly denies any thoughts of suicide
b.A 30-year-old female who has been hospitalized overnight on several occasions for attempted suicide
c.A 50-year-old recently divorced alcoholic male who feels life is hopeless
d.A 50-year-old female who thinks of suicide and fears she might act on her thoughts

C

Assessment of suicidal risk is critical in determining the need for and duration of hospitalization of depressed patients. Most suicides are planned, not impulsive, and carried out successfully most often by the elderly, males, those in poor health, alcoholics, schizophrenics, those who have recently lost a loved one (especially a mate), and those suffering from depressive disorders. Many depressed patients think about suicide, and a physician should take these patients seriously; however, among this group of patients, the 50-year-old recently divorced alcoholic male has the highest risk of successful suicide.

Suicide took the lives of 30,575 Americans in 1998 (11.3 per 100,000 population).

More people die from suicide than from homicide. In 1998, there were 1.7 times as many suicides as homicides.

Overall, suicide is the eighth leading cause of death for all Americans, and is the third leading cause of death for young people aged 15-24.1

Males are four times more likely to die from suicide than are females.1 However, females are more likely to attempt suicide than are males.

1998, white males accounted for 73% of all suicides. Together, white males and white females accounted for over 90% of all suicides.1 However, during the period from 1979-1992, suicide rates for Native Americans (a category that includes American Indians and Alaska Natives) were about 1.5 times the national rates. There was a disproportionate number of suicides among young male Native Americans during this period, as males 15-24 accounted for 64% of all suicides by Native Americans.

Suicide rates are generally higher than the national average in the western states and lower in the eastern and midwestern states.

Nearly 3 of every 5 suicides in 1998 (57%) were committed with a firearm. (source:CDC

Clear contraindications to the use of thrombolytic agents in the setting of an acute anterior myocardial infarction include all the following EXCEPT

A left carotid artery occlusion with hemiparesis 1 month ago
B transurethral resection of the prostate 1 week ago
C diastolic blood pressure of 110 mmHg during chest pain
D patient age greater than 70
E epigastric pain and melena 1 week ago treated with histamine receptor antagonists

The answer is D
While prompt initiation of thrombolytic therapy during an acute myocardial infarction is associated with improvement in mortality and limitation of the size of the infarct, all thrombolytic agents, including tissue plasminogen activator, are associated with an increased risk of major bleeding. These agents should not be given if there is a history of a cerebrovascular accident, a surgical procedure within the past 2 weeks, active peptic ulcer disease, or marked hypertension during acute presentation (systolic pressure greater than 180 or diastolic pressure greater than 100 mmHg). Other situations in which the risk of bleeding may be higher, such as advanced age, are not absolute contraindications, but the potential benefit from the administration of thrombolytic therapy should be considered carefully in each case.

A pregnancy is confirmed in a 30 year old woman with an IUD in place. The woman expresses a strong desire to continue pregnancy. The most appropriate course of action is to

a. leave the IUD in place without any other treatment
b. leave the IUD in place and give prophylactic antibiotic
c. remove the IUD immediately
d. terminate pregnancy

Answer is C.
Although there is increased risk of spontaneous abortion, and a small risk of infection, an intrauterine pregnancy can occur and continue to term with IUD in place but IUD should be removed in an attempt to reduce the infection, abortion, or both.

Pulmonary embolism

EKG
oxygen
pulse oximetry
CXR
iv access
CBC
PT
PTT
ABG
V/Q scan: if +, then anticoagulation: heparin for 1 week + warfarin (coumadin) for 3 month. Check PTT every 4 hours till 1.5 to 2 times control. Keep INR PT 2-3. If V/Q -, then duplex ultrasound of lower extremity for DVP. If +, anticoagulation, if -, pulmonary angiography.
If bleeding occur, stop heparin and warfarin, put inferior vena cava filter
consider thrombolytiic therapy (tPA or streptokinase) if massive PE who are hemodynamically unstable.
Embolectomy if thrombolytic therapy fail or is contraindicated.

Addition. Interpretation of V/Q Scan

Yes patient should be hospitalized..

Interpretation of V/Q Scan


Scan.High probability
Clinical. High or intermediate
Probability. 96% +
Managegment. Treat for PE

Scan.Medium probability
Clinical. Low
Probability. 12%
Management. *Need further evaluation

Scan.Medium probability
Clinical. Intermediate
Probablity. 33%
Management. *Need further evaluation

Scan.Low probability
Clinical. High
Probability. 16%
Management. *Need further evaluation

Scan.Low probability
Clinical. Low
Probability. 4% <
Management. No PE

Normal
Clinical. Low
Probability. 2%
Management. No PE

NOTE: Any other combination of results is not helpful and patients should have other testing.
*Start with Doppler of a swollen leg and then angiography if Doppler is negative